Examining the awareness, acceptability, and adoption of conventional and non-conventional forms of Pre-Exposure Prophylaxis (PrEP) for HIV prevention among jail-involved Black sexual minority men (BSMM) and Black transgender women (BTW) in two diverse US cities

Introduction

Black sexual minority men (BSMM) and Black Transgender women (BTW) are disproportionately impacted by HIV and incarceration in the United States (US).^1,2,3,4 BSMM nationally accounted for approximately one-quarter of all HIV diagnoses in 2019. The majority (75%) of BSMM who received an HIV diagnosis that year were 13–34 years of age.¹ Among transgender individuals, more than half of all new HIV diagnoses occurred among BTW.² High incarceration rates have also been documented among BSMM and BTW. For example, a six-city US study showed elevated lifetime history of incarceration (60%) and incidence (34%) among BSMM and BTW.^3,4 In addition, the odds of incarceration history were significantly higher among BTW compared with BSMM (80.0% vs 59.7%; p = .025).³

Correctional settings such as jails and prisons are considered high priority HIV prevention settings.^5,6 They offer a unique opportunity to deliver Pre-exposure prophylaxis (PrEP), during detention, immediately prior to release, and/or post release, particularly for those already on PrEP.^6,7 Compared with prisons, jails are usually operated by local (i.e., city and county) government and they typically house three main types of detainees: (a) those who have been arrested and are awaiting trial, a plea agreement, or sentencing; (b) those who have been convicted and are serving a sentence of less than a year; and (c) individuals who have been sentenced awaiting transfer to a prison.^8,9 Thus, PrEP delivery may be particularly challenging within jails given that most jail detainees are released into the community after an average stay of less than a month⁹ which provides a limited window of opportunity to prepare for and/or delivery PrEP.

Studies have documented HIV transmission during periods of incarceration.^10–12 However, there is broad consensus that most new HIV infections occur pre-and-post detention.^13–15 The transition from correctional settings to community for many BSMM and BTW represents a particularly vulnerable period of time where transactional sex, new sex partners, substance use, and social instability are observed with associated increases in HIV transmission and acquisition.^13–22

PrEP is an effective biomedical HIV prevention strategy^23–25 and is recommended by the Centers for Disease Control and Prevention (CDC) for all individuals at substantial risk for HIV.²⁵ Conventional PrEP delivery (i.e., oral PrEP daily dosing based upon CDC guidelines) involves a series of steps including: assessment of risk for HIV acquisition; confirmation of HIV negative status; and conducting other laboratory tests (e.g., creatinine, hepatitis B) prior to PrEP administration.²⁵ The majority of PrEP studies have focused on non-institutionalized BSMM and BTW populations^26–31 with significant gaps pertaining to PrEP implementation within correctional settings, prior to release, and immediately following release.^32–35

Non-conventional PrEP strategies such as long-acting injectable (LAI)-PrEP³⁶ and PrEP e-prescription (i.e., providing a month’s supply of PrEP to be picked up at a pharmacy post release), may also be useful for jail-involved BSMM and BTW. LAI-PrEP, currently intramuscular cabotegravir, was recently approved by the Food and Drug Administration (FDA) for use in at-risk adults and adolescents to reduce the risk of sexually acquired HIV.³⁶ LAI-PrEP is administered as a single intramuscular injection every two months after two initiation injections administered one month apart with an optional oral lead-in to assess tolerability.^{37, 38} LAI-PrEP may be particularly beneficial if implemented prior to release as it would provide an extended level of protection post release for BSMM and BTW.

In the current Justice-Pre-Exposure Prophylaxis (J-PrEP) study, we examined the awareness, acceptability, and early adoption of conventional (i.e., daily oral pill) and non-conventional forms of PrEP (i.e., LAI-PrEP, and e-prescribed PrEP) among jail-involved BSMM and BTW. We used the Exploration phase of the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework to guide our study. We focused on the inner context of the Exploration Phase to include jail setting and adopter (i.e., BSMM/BTW) characteristics that may facilitate or hinder PrEP implementation and adoption.³⁹

Methods

Partnerships and Recruitment.

The J-PrEP study was led by the University of Chicago (UC) in partnership with a community-based organization (i.e., the Capitol Area Re-entry Program [CARP]) in Baton Rouge, Louisiana. Participants were recruited from ongoing UC studies, group-level programs, and from flyers posted at community-based organizations and in health clinics. In order to be eligible for the J-PrEP study, individuals had to meet the following criteria: (1) self-report that they were Black, African- American, or multi-ethnic Black, (2) self-report that they were 18 to 34 years of age, (3) report that they were assigned male at birth, (4) identify as a transgender woman or as a cisgender man who reported that they were either gay, bisexual, same-gender loving, queer, and/or had sex with another man in the last 2 years, (5) report a jail stay within the last 24 months for at least 24 hours prior to study participation, (6) provide a confirmed HIV negative test at enrollment, (7) report that they currently resided in the Chicago or Baton Rouge area, and (8) were able to complete the study in English and provide consent. J-PrEP was focused on enrolling younger BSMM and BTW given the substantial burden of HIV among younger Black sexual and gender minority individuals.^1,2

Potential participants were screened by UC and CARP staff and excluded if they were currently incarcerated or on parole/probation. Eligibility screening was conducted in person or over the phone to confirm study eligibility. Consent was obtained from eligible participants prior to enrollment. The study was approved by UC’s Institutional Review Board.

Study Design and Measures.

Participants completed a brief survey and an in-depth, in-person or virtual interview that lasted about an hour. The survey assessed demographic characteristics (e.g., age, race/ethnicity, education level, housing status, income level, health insurance coverage, gender identity, sexual orientation) and PrEP-related characteristics such as PrEP knowledge, perceptions, and current/previous conventional PrEP utilization. In-depth interviews were conducted by trained staff using a semi-structured interview guide. All interviews were audio recorded with participant permission and transcribed verbatim by an external transcription agency. Participants were compensated $40 cash for their time.

Data Analyses.

Survey responses were compiled and aggregated for analysis. Descriptive analysis was conducted in STATA software version 17⁴⁰ to characterize the sample. We report descriptive statistics by city (i.e., Chicago versus Baton Rouge) in Table 1. We also report the proportions of PrEP-related characteristics in Table 1. A team of three trained individuals conducted ongoing thematic analysis of the interview transcripts. An initial code book was developed prior to analyzing the interviews. The analysis team read and re-read the first set of transcripts independently and coded them using the initial code book. Once the initial set of transcripts were coded, the team meet virtually to discuss the themes, why specific themes were selected, and to discuss any discrepancies in coding. The code book was subsequently updated to reflect any new and/or more appropriate codes. Inter-rater reliability was tested and found to be 96%. The analysis team continued to code additional transcripts independently and met weekly to discuss the transcripts. Final agreed upon codes were entered into DeDoose (version 9.0.17)⁴¹ with their corresponding excerpts from the transcripts. Codes attached to the primary research questions were reviewed to organize findings and develop a better understanding of the barriers and facilitators tied to the implementation and adoption of: 1) conventional PrEP; 2) LAI-PrEP, and 3) PrEP post release (i.e., e-prescription).

Table 1.

Demographic and Socioeconomic Characteristics among jail-involved BSMM and BTW participants in Baton Rouge and Chicago (N=34)

	Baton Rouge (n=12)		Chicago (n=22)		Total (N=34)
	n	%	n	%	N	%
Demographic Characteristics
Age (mean age 23.6, standard deviation = 3.9)
18–24	11	97.7	11	50.0	22	64.7
25–29	0	0.0	10	45.5	10	29.4
30–39	1	8.3	1	4.5	2	5.9
Latinx	0	0.0	4	18.2	4	11.8
Gender
Cisgender man	12	100.0	18	81.8	30	88.2
Transgender woman	0	0.0	4	18.2	4	11.8
Sexual Identity
Gay/Same Gender Loving	10	83.3	0	0.0	10	29.4
Bisexual	2	16.7	6	27.3	8	23.5
Straight	0	0.0	10	45.5	10	29.4
Other	0	0.0	4	18.2	4	11.8
Relationship Status (Single)	12	100.0	21	95.5	33	97.1
Socioeconomic Characteristics
Education
Less than High School (HS)	1	8.3	7	31.8	8	23.5
HS or GED equivalent	8	66.7	8	36.4	16	47.1
Some college or more	3	25.0	6	27.3	9	26.5
Unemployed	12	100.0	18	81.8	30	88.2
Income (Less than $1000 per month)	10	83.3	13	59.1	26	67.6
Unstable housing (Yes)	0	0.0	7	58.3	7	20.6
Medical Insurance (Yes)	5	41.7	17	77.3	22	64.7

Results

A total of 34 individuals participated in the J-PrEP study with a mean age of 23.6 (standard deviation, 3.9), across Chicago, IL (n=22) and Baton Rouge, LA (n=12). The majority (65%, n=22) of all participants were 18–24 years of age. All participants identified as Black, African American, or of Black mixed heritage. Four participants, all from Chicago, also identified as Latinx. Eighty-eight percent (88%, n=30) of all participants identified as cisgender men and only 12% (n=4) as transgender women. Almost 30% of participants identified as either gay/same gender loving or straight and close to 25% as bisexual. Almost half of all participants (47%) had a high school or GED equivalent, 68% had a monthly income of less than $1,000, and 88% were unemployed. One-fifth (20.6%) of participants reported unstable housing and most participants (65%) had medical insurance.

PrEP-related characteristics are described in Table 2. The majority of all participants (80%) had heard about PrEP and 56% had a provider talk to them about PrEP. Forty-four percent (44%) of all participants reported that a provider had recommended PrEP. About a third of all participants (32%, n=11) reported that they were currently using PrEP, with only 45% (n=5) of current PrEP users reporting that they received it from a provider. The other 45% (n=5) of current PrEP users indicated that they received PrEP from friends. More than two-thirds of all participants (68%) reported that they knew someone who was currently on PrEP. Twelve percent (12%, n=4) of all participants had received PrEP in a jail setting and 32% (n=11) had received an HIV test in a jail setting. The majority of all participants reported that they were extremely likely or likely to get an HIV test in a jail setting (71%, n=24), to use PrEP in a jail setting (62%, n=21), or to receive a PrEP e-prescription for pick up post release (59%, n=20).

Table 2.

Pre-exposure prophylaxis (PrEP) characteristics among jail-involved BSMM and BTW in Baton Rouge and Chicago (N=34)

	Baton Rouge (n=12)		Chicago (n=22)		Total (N=34)
	n	%	n	%	N	%
PrEP Questions
Heard about PrEP	7	58.3	20	90.9	27	79.4
Provider talked about PrEP	4	33.3	15	68.2	19	55.9
Provider recommended PrEP	2	16.7	13	59.1	15	44.1
PrEP use (current)	1	8.3	10	45.5	11	32.4
PrEP source (among PrEP users only)
Primary care provider (PCP)	1	100.0	1	10.0	2	18.2
Other provider	0	0.0	3	30.0	3	27.2
Friend	0	0.0	5	50.0	5	45.5
Don’ know/Refuse	0	0.0	1	10.0	1	9.1
Knows someone who currently uses PrEP	5	41.7	18	81.8	23	67.6
Likely to use PrEP in a jail setting
Extremely likely	4	33.3	12	54.5	16	47.1
Likely	2	16.7	3	13.6	5	14.7
Undecided	3	25.0	4	18.2	7	20.6
Unlikely	3	25.0	2	9.1	5	14.7
Extremely Unlikely	0	0.0	1	4.5	1	2.9
Likely to use e-prescribed PrEP
Extremely likely	4	33.3	9	40.9	13	38.2
Likely	2	16.7	5	22.7	7	20.6
Undecided	2	16.7	5	22.7	7	20.6
Unlikely	4	33.3	3	13.6	7	20.6
Extremely Unlikely	0	0.0	0	0.0	0	0.0
Received PrEP in jail setting	0	0.0	4	18.2	4	11.8
Likely to get HIV test in jail setting
Extremely likely	4	33.3	11	50.0	15	44.1
Likely	2	16.7	7	31.8	9	26.5
Undecided	2	16.7	0	0.0	2	5.9
Unlikely	4	33.3	2	9.1	6	17.6
Extremely Unlikely	0	0.0	0	0.0	0	0.0
Received HIV test in jail setting	1	8.3	10	45.5	11	32.4

Major interview themes related to Conventional PrEP in Jail

Participants responded to a future scenario in which PrEP may be provided in jails. They were asked if they had heard about this approach (i.e., awareness), who they had heard about it from, if it was currently offered in jails (i.e., availability), and what they thought about this approach (i.e., acceptability, barriers, and facilitators).

Participants in Baton Rouge were largely not aware of PrEP being provided in jails. However, one Baton Rouge participant recalled hearing about PrEP while they were incarcerated. – “I have -- like I’ve heard it (PrEP) going around before, but it was never like, out like that, it will be small conversations or people whispering about it and then they stop talking about it. As it was time for me to leave, I started seeing stuff about it like in certain parts, but it wasn’t like all around the jail. It was mostly inside certain sections that you would see it unless you would hear certain people talk about it.” Awareness of conventional PrEP in jail varied between cities and is most likely attributed to the availability of PrEP in one city (Chicago) versus the other (Baton Rouge).

Awareness of PrEP in jail varied between BTW and BSMM in Chicago. All BTW were aware of PrEP in jail, including receipt of PrEP while incarcerated in the Cook County area. A few BSMM in Chicago had heard about PrEP while they were in jail from various sources such as their cellmates or friends, but most had not utilized PrEP while incarcerated. - “It was kind of like, I mean he (cellmate) told me about it, I know he told me like his girl was taking it (PrEP), but I mean it was kind of like a short talk, and he was like yeah bro, it prevents HIV. And always as a kid I knew HIV was around but I didn’t know if there was a cure for it but I didn’t know there was a pill to prevent it….so he telling me this, and I’m like huh and now he put me up onto something and now I got like a little awareness but I’m locked up so I never really you know what I’m saying, I couldn’t look it up actually, go look at it, so yeah.” Additionally, participants receiving PrEP while incarcerated in Chicago uniformly endorsed having a positive experience overall. – “At Cook County if you tell them you take PrEP they are going to look into your records and stuff like that and they are going to get you your PrEP. It takes about two days or so but then you get your PrEP and all that stuff. So, I think that was really good with that.”

A common theme that emerged when discussing the acceptability of conventional PrEP in jail was the belief that PrEP implementation was important because people who are detained do have condomless sex while incarcerated. While most new HIV infections occur in community settings, many participants believed that the risk of HIV transmission in jail was high. Thus, the majority of participants believed that implementing PrEP in jail was very important and therefore was a very acceptable idea. This was discussed among participants who had received PrEP in jail as well as those who had not.

- “I think it [PrEP in Jail] is very important, I mean personally I’ve been in and out of jail for a couple of years and I think I mean whether –I am just being transparent with you, you know, whether America or the guards believe it sex goes on in jail and they won’t issue out any condoms or anything, because they’re like, hey, we don’t do -- it’s not like we condone you or what’s going on, but I believe that that is something that need to be administrated in jail because sex does happen and I think that’s a way of helping the ones that are in jail prevent from spreading HIV because they mix us up anyway.” Baton Rouge participant

- “I think it should be offered in jail because especially for people that’s negative when they come in because I know so many people that’s negative when they come in, when they come out, they probably don’t. And then well, because they know people are going to have sex or in case maybe, or not it, whether it’s forcefully or not forcefully they still should take the PrEP.” Chicago participant

When discussing barriers and facilitators to the adoption of conventional PrEP in jail, two major themes emerged: PrEP would provide peace of mind; and the stigma of PrEP might present some challenges for people in jail who decide to take it. The majority of participants believed that PrEP in jail would provide safety and peace of mind as contracting HIV is a concern for them and PrEP would alleviate some of that worry. – “Like I said if you have PrEP in jail because the stuff (sex) happens that would be safer knowing like oh, I’m on my PrEP just in case anything happened I would be safe well, it’s hard to be safe but the prevention from HIV would be better. And then you know some guys that are in jail already gay or bisexual so if they’re on PrEP they can do what they want to do and not having to worry about it.” Chicago participant

A few participants also alluded to non-consensual sex in jail which has been documented in the literature⁴⁰ and therefore PrEP would also be needed in those instances. – “So, if a person decides that they want have sex while being incarcerated, it’s a possibility that that can definitely happen. You’re not being monitored like that. People may talk, but it isn’t nothing like getting a little quickie in, however, if somebody want to be on PrEP in jail, you still want to be safe…I know somebody that don’t have sex, but they are still on PrEP because believe it or not, it’s sick as hell, but it’s a sick world. You know, it’s an imperfect world, people can get raped. You don’t want to become the victim of having HIV transmitted to you. You know what I’m saying? You didn’t even want to have sex.” Chicago participant

While participants believed that the provision of PrEP in jail was an acceptable idea, they were concerned about the stigma attached to PrEP and any negative consequences that may arise (e.g., violence) if other incarcerated individuals found out about their PrEP usage.

- “Some of the other inmates it wouldn’t be their business but like to ask you what the pill is for because if you ever had I don’t think you’ve ever been in there I mean it is not but um, they exchange medications in jail sometimes because you know, I wanted lunch and you want to have this high. So, here’s the pill that they gave me – for me to be on some valium and then I can go ahead and get your lunch. But to ask somebody is that valium and then you have to explain ‘Oh, this is PrEP, this is for my sex,’ and then somebody says, ‘Well, why are you taking a sex pill in jail, and we don’t want you,’ and then it becomes like a violence thing because nobody wants to be a bully. That’s the only drawback that I can see of taking PrEP inside of the prisons.” Chicago participant

- “…but like you’re going to have homies in there that know you just from the block. So, I think it is one of those things like even they get caught so they might go tell people from his neighborhood like oh he taking this and they might think why is he doing that, like kind of just spreading the word without bringing out personal information, that’s not supposed to be spread.” Another Chicago participant

One BTW participant in particular discussed her experience taking PrEP while incarcerated and what happened when other people found out. - “It was like at first you had to school them because the guys thought that that was something that if you have HIV, you take it. So, they were like, ‘You was on the blue pill?’ and I’m standing there and like I had to tell them, ‘No, that’s to prevent it.’ I had to school them when I first got there.” Chicago participant

Major interview themes related to a PrEP E-Prescription Strategy

Participants were provided a future scenario with PrEP e-prescription for pick up from a pharmacy post release. They were asked if they had heard about this approach (i.e., awareness), if it was currently offered in jails (i.e., availability), and what they thought about this approach (i.e., acceptability, barriers, and facilitators).

Participants in both cities were largely not aware of this approach. This approach was provided in Cook County jail as described by one Chicago participant. Participants in both cities largely believed that this strategy would be good idea. Two major benefits of this strategy emerged from the transcripts. One benefit of this strategy was that it would help support continuity of PrEP care post release. - “I think it’s very important because if they want to give it to them while they’re in jail, you might as well keep it going but you don’t want to get them off the regimen so they’re already been taking it, they’re provided and they’re used to it. So, I feel like you know, it’s a good thing to give it to them.” Baton Rouge participant

Second, aligned with the first barrier, several participants suggested that this strategy would alleviate a barrier to healthcare, that is, the urgent need to find a provider to prescribe PrEP so an automatic e-prescription would provide some time (i.e., 30 days) to find a provider as stated by a participant in Baton Rouge - “Yeah, I think it’s a good idea because once you get out you have to find a new doctor to provide the prescription. So, it really gives them a little time to get to the doctor.”

Participants also noted that receiving PrEP post release (i.e., an automatic e-prescription for pick up) would certainly reduce their likelihood of acquiring HIV when they returned to their communities upon release. Participants discussed people wanting to engage with previous sexual partners and regain control of their lives when released.

- “I think that that could be beneficial, especially for someone who is just getting out of jail because you have a lot of more freedom to do whatever you want. So, you might be a little more sexually active getting out of that situation than being in it. So, I think that it’s great, it’s beneficial.” Baton Rouge participant

- “Well the reason why I think it’d be great. You got a lot of people down here, don’t play it safe so when they come home, they want to do this, they want to do this, and they be so like into like what they are trying to get themselves into, so they are like not even aware of. They’re so quick, oh man I ain’t have none in a long time, then you slip up, now you get HIV or something.” Chicago participant

Interestingly, a participant in Chicago did mention the added complexity of staying on PrEP if an individual was on house arrest. – “Then also some people may get out and be on house arrest and stuff like that and can’t get movement right now, not just getting out until the judge set out things and set up bail and everything has been finalized, which may take a couple of days or something.” It is important to note that for house arrest persons, anyone including a designee can pick up the prescription. The electronic monitoring program also allows patients access to pick up medications and attend provider appointments. However, they have to be pre-approved for medical movement.

A common theme that emerged in both cities as a potential barrier to e-prescription post release was possible misuse of the pills. A few participants in Chicago mentioned that some individuals might try to sell the pills instead of taking them. “They are not going to take it. They are not going to take it at all. Once again, they might try to sell on the streets, for like different drugs, get to their own people who don’t want to be taking it. They might not follow that with the schedule.”

Major interview themes related to LAI-PrEP in Jail

Participants were presented with a future scenario that consisted of LAI-PrEP. They were asked if they had ever heard about this approach (i.e., awareness), if it was currently offered in jails (i.e., availability), and what they thought about this approach (i.e., acceptability, barriers, and facilitators). Participants in both cities were largely not aware of an injectable form of PrEP being available in the near future. However, after discussing the possibility of LAI-PrEP being available to people upon release, participants were very receptive. – “Now that will be a perfect idea because it’s in their system when they are leaving out, versus the pill. I know a lot of people when they get out, they go to the doctor. They keep going to the doctors and stuff. I think that should be appropriate.” Chicago participant

Participants in both cities stated that having an injectable form of PrEP would be very beneficial as they would not have to worry about taking a pill every day.

- “They are not going to worry about pills for one, being consistent about taking a pill every day, because some people can get real busy and just forget about it.” Chicago participant

- “I think that that could be effective -- very, very effective. Especially if it holds you off for four weeks because some people don’t like taking pills. For me personally, I don’t like taking pills. So, I guess, yeah, that’s way more effective. It’s kind of like birth control with females… ‘so, you like the shot or like the pills?’” Baton Rouge participant

Some participants in both Chicago and Baton Rouge also mentioned that receiving LAI-PrEP would help reduce the stigma of taking conventional PrEP because it would be harder for people to know that they were on PrEP.

- “Yes, like I feel like that’d be great in jail because a lot of people won’t have to worry about getting in pill line like you could come secret - I would like to come take a PrEP shot. Put it into me and nobody gotta know. You just receive a little healthcare pad and then you go to healthcare. Won’t nobody know.” Chicago participant

- “I’ve never heard about that before but that actually it might be better than somebody having to take it every day. One shot every month as long as you’re going. Once a month, you’re good, nobody is questioning you go into the doctor for a five-minute shot. Oh, I’ll be right there, I have an appointment. So, nobody heard about it.” Baton Rouge participant

Although participants were largely receptive to LAI-PrEP, they expressed some challenges to its adoption compared to other PrEP delivery options. Some participants stated that others might not like the idea of receiving an injectable form of PrEP because they do not like needles and that this would present a challenge to adoption. - Well, I guess it depends on the person to be honest, you know, getting stuck with the needle. I feel like that’s a lot more to go through than taking a pill to be honest.” Baton Rouge participant

A few BSMM participants in Chicago discussed LAI-PrEP as a necessary option in a jail setting but they indicated that such a new biomedical HIV prevention intervention would add additional time to an already packed and complicated medical visit. - “I feel like the pill would be more (less) extreme because you get the shot, they gone try to drag that process on and you’re going to be sitting there waiting for a long time to get this shot to leave out. I don’t feel like people got that much patience knowing they about to leave out; why it take it forever for the doctor to come get them for one shot..the process is already really slow.”

Interestingly, a participant in Chicago was afraid that LAI-PrEP may be provided by correctional officers and stressed that it should be provided by competent staff. “The only thing that I can think of is I hate to speak at a time because it’s not everybody, but some of those prison guards are only there to get a check and you just never know how they are going to abuse their authority. And since somebody cannot inject themselves with the medication, my only take back will be to make sure that you have somebody who is completely sane in the mind and does not have a malicious attitude to administer those shots for the inmates that are also often looked at as just criminals instead of somebody who has a family and just ordinary human being.”

Discussion

The J-PrEP study examined the awareness, acceptability, barriers, and facilitators to the early adoption of conventional and non-conventional forms of PrEP among justice-involved HIV negative BSMM and BTW. This study is among the first to explore different PrEP delivery strategies among jail-involved BSMM and BTW. Participant responses confirmed that PrEP was appropriate and needed within jail settings given reported instances of consensual and non-consensual forms of sex in jails as well as limited condom access/availability discussed in the literature.⁴² PrEP is also needed and appropriate post release given reported sexual risk behaviors post release.

Our qualitative study revealed that Chicago participants were largely aware of PrEP and that it is more readily available in Chicago jails compared with Baton Rouge jails. None of the Baton Rouge participants had ever received PrEP in a jail setting while four participants had received PrEP in Chicago jails, three of whom were BTW. General PrEP awareness and uptake in Chicago may be due to a variety of efforts including educational sessions with Cook County Jail health care providers, access to clinical medical education focused on PrEP for providers, a transgender health expert at Cook County Jail, and Chicago’s PrEP4Love campaign.⁴³ Low PrEP awareness in the Deep South, such as in the Baton Rouge area, compared with other US regions is consistent with previous study findings.⁴⁴ Future studies should address general PrEP awareness and uptake in the Baton Rouge area among BSMM and BTW if it is to be implemented within jail settings.

Although participants were largely receptive to PrEP within jails, they believed that the stigma related to PrEP usage would be a significant barrier to the full implementation of PrEP. Many participants worried that if they received PrEP in jail, they would face judgement or backlash from other detainees. This finding is consistent with Brinkley et al.’s study which examined the perceptions of PrEP interventions in correctional settings among incarcerated sexual minority men.⁴⁵ It is important to note that some BSMM and BTW may be housed in protective custody. Therefore, an individual’s level of PrEP stigma may be influenced by where they are housed within correctional settings. Participants also worried about experiencing prejudice and discrimination from jail staff. Thus, future PrEP implementation programs within these cities should pay attention to PrEP-related stigma experiences as well as potential drivers of stigma (e.g., jail staff) if PrEP interventions are to be introduced within jail settings.

This study also provided useful information surrounding LAI-PrEP for jail-involved BSMM and BTW. Our findings revealed that although participants were largely unaware of injectable PrEP, which is FDA approved, there was great interest in its adoption. Participants suggested that injectable PrEP would alleviate some of the stigma surrounding PrEP because it would be difficult for others to know that they were on PrEP. LAI-PrEP would also enhance continuity of care and provide longer-term protection. However, participants did foresee needle aversion as a challenge to LAI-PrEP adoption among detainees. Given that most jail detainees are released in the community after a short stay, there is an added challenge of providing the initial two injections one-month apart with an optional oral lead-in for injectable PrEP. Future studies should further examine ways to provide LAI-PrEP within jail settings.

Conclusion

This study has several limitations. Our findings cannot be generalized to all jail-involved BSMM and BTW given the non-representative sample of participants. Our findings are limited to participants with a recent jail history as the study did not enroll individuals who were on parole/probation and former prisoners. We also only enrolled four BTW in the study, thus findings specific to BTW should be interpreted with caution. Study findings cannot be generalized to other jurisdictions given it was conducted in two cities. It is important to underscore two key differences between the jail-involved participants from the two cities. First, no one in the Chicago sample identified as gay or same gender loving while almost all of the participants in Baton Rouge did. Second, a majority of those in Chicago were unstably housed while none of the Baton Rouge participants reported housing instability. Such demographic and social characteristics may be important considerations for future multi-site PrEP interventions.

The current study documented ways in which PrEP may greatly benefit BSMM and BTW while incarcerated or immediately post release. In addition to uncovering context-specific barriers and facilitators to PrEP adoption among jail-involved BSMM and BTW, the J-PrEP study also provided insight into the overall implementation of PrEP within jail settings and immediately following release. For example, it might be beneficial to include an education component for BSMM and BTW within a future PrEP implementation study in Baton Rouge jails. It would also be important to monitor pill sharing among BSMM and BTW, particularly in Chicago, given that 45% of Chicago participants on PrEP reported receiving it from friends.